Symmetrical Peripheral Gangrene Associated with Low Output Cardiac Failure

Symmetrical peripheral gangrene (SPG) is a rare entity characterized by ischemic changes of the distal extremities with maintained vascular integrity. We present the case of a 64-year-old man with bilateral necrotic toes and deranged liver function tests. This was thought to be related to severely depressed ejection fraction from non-ischemic etiology, presumably chronic alcohol ingestion. We hope that awareness of SPG and association with a low output state will aid in early detection and prevention.

Postoperative nutritional support of the patient with gut gangrene-a case report

BACKGROUND

Bowel necrosis is a commonly observed condition in elderly patients with longstanding diabetes. In such condition, intestinal resection is usually performed for the removal of the gangrenous part. Post-surgical dietary management after bowel resection poses several challenges for the health care team.

CASE PRESENTATION

The case presented in this study is that of an elderly diabetic male who developed acute renal failure as a result of neglect in post-surgical feeding after intestinal resection. After the intervention by a trained dietitian, a transitional diet was planned and successfully executed, resulting in reversal of acute renal failure, dehydration, and post-surgical stress. Several complications including hepatic dysfunction and mouth ulcers were resolved through well-planned transitional diet. The patient was finally discharged in a stable health condition and was regularly followed up for any nutritional or medical issues.

CONCLUSION

Neglects in nutritional care of patients can have severe implications including development of medical complications, resulting in increased length of hospital stay, augmenting the disease stress of the patient and family, and finally the preventable drainage of several human and monetary resources. Therefore, recognition of nutritional intervention as an important part of in-hospital health care may have social as well as economic impacts.

Resolution of Primary Aortic Thrombosis after Dabigatran therapy-A New Hope for the Rare and Old Disease

The primary aortic thrombosis (PAT) is an uncommon noncardiac cause of distal peripheral embolization to lower extremities. Also, this condition develops in the absence of extensive atherosclerosis of aorta or abnormal dilatation like aneurysm of the aorta. In most of the cases, there was either no or minimal atherosclerosis of the aorta. The disease can involve any part of the aorta, but in most of the cases, the thoracic aorta below the origin of the left subclavian artery followed by the infrarenal portion of the abdominal aorta was the most common site of involvement. In our case, there was extensive thrombosis starting from the lower part of the thoracic aorta extending across both the renal arteries up to the aortic bifurcation without any underlying aortic pathology or hypercoagulable disease. There are no guidelines for the management of the PAT, but our experience is based on few case series, case reports, and meta-analysis where there are variable success rate using conservative medical management, endovascular procedure, or surgical thrombectomy. Vitamin K antagonist was the drug of choice in all the cases as a part of conservative medical management or used to prevent recurrence after the endovascular or surgical procedure. We present a case of PAT where the use of dabigatran leads to complete resolution and prevented the recurrence of the disease during two-year follow-up, which is the first and unique case report of the literature.

Operative versus non-operative treatment in diabetic dry toe gangrene

BACKGROUND AND AIM

Diabetic foot is a major comorbidity of diabetes, with 15-25% of diabetic patients developing diabetic foot ulcer during their lifetime. Other major diabetic foot complications include cellulitis, abscess, wet gangrene, dry gangrene, and necrotizing fasciitis. Dry gangrene involves tissue necrosis due to chronic ischemia whereby the tissue becomes numb, dry, wrinkled, and dead. Although diabetic foot complications have been extensively studied in literature, there is limited data on the management of dry gangrene.

METHODS

We report a case series of 12 patients with diabetes-related dry gangrene in the toes, initially planned to be managed conservatively with autoamputation.

RESULTS

One patient had an autoamputation, while eight patients underwent surgical amputations (six major amputations, two minor amputations) for better clinical outcomes. Two patients died, while no change was observed in one patient even after 12 months of follow-up.

CONCLUSION

Managing diabetic dry toe gangrene by waiting for autoamputation may lead to worse clinical outcomes and should be practiced cautiously on a case-by-case basis. Early surgical intervention should be opted to improve patients' quality of life.

Scrotal necrosis and no Fournier's in sight: a rare case of juvenile gangrenous vasculitis

Juvenile gangrenous vasculitis of the scrotum is a rare entity, of which to our knowledge we describe the first documented case in the UK. It follows a typical disease course, demonstrated by an 18-year-old male who presented with three necrotic scrotal lesions; proceeded by 3 days of fever, pharyngitis and lethargy. Previous cases have been managed successfully with systemic steroids. On this occasion, surgical debridement was made of the necrotic areas under antibiotic cover and complete resolution was achieved with excellent wound healing and no evidence of recurrence. This case report discusses the importance of disease recognition and the merits of surgical management. We also add to the debate as to whether this disease is a variation of pyoderma gangrenosum or a distinct entity itself within the pantheon of scrotal gangrene.

Elevated serum bilirubin levels may predict perforation of the appendix

AIM

Acute appendicitis is one of the most common pathology requiring emergency operations, and if perforated, can cause morbidity and mortality. The serum bilirubin levels were studied to see whether an elevation predicted perforation.

MATERIAL AND METHODS

In a retrospective cohort study the medical files of 221 patients who were operated for acute appendicitis were reviewed.

RESULTS

Total and indirect bilirubin levels were significantly higher in patients with a perforated appendicitis compared with patients with simple appendicitis. Elevated serum bilirubin had a sensitivity of 50.00 (95% CI 29.93 to 70.07) and a specificity of 80.73 (95% CI 74.43 to 86.05) when predicting a perforated appendicitis.

CONCLUSIONS

Appendiceal perforation may be accompanied with elevated serum bilirubin level. Assessment of bilirubin levels must be a part of the initial evaluation of a suspected appendicitis in the emergency room.

KEY WORDS

Acute appendicitis, Gangrenous appendicitis, Perforated appendicitis, Serum bilirubin, Total Hyperbilirubinemia.

Systematic review of pharmacological therapies for the management of ischaemic pain in patients with non-reconstructable critical limb ischaemia

BACKGROUND

Critical limb ischaemia (CLI) is a severe manifestation of peripheral arterial disease, characterised by chronic ischaemic rest pain, ulcers or gangrene. Management of ischaemic pain is challenging in patients with no options for revascularisation and optimal pharmacological therapies have not been established.

OBJECTIVES

To identify and evaluate the effectiveness of pharmacological therapies to treat ischaemic pain secondary to non-reconstructable CLI.

METHODS

This systematic review was reported in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline. Comprehensive searches of three electronic databases, a PubMed-related articles link search, grey literature search and hand-searches of the bibliographies of relevant papers and textbooks were performed. Studies recruiting adult patients with CLI of any aetiology were eligible for inclusion. Surgical and revascularisation procedures, and all invasive interventions were excluded.

RESULTS

Of 792 studies, six met full inclusion criteria. These studies researched the use of intravenous lidocaine, intravenous ketamine, oral gabapentin and the combination of transdermal buprenorphine and epidural morphine/ropivacaine infusion. All studies showed an improvement in severity of ischaemic pain in CLI but with varying side effect profiles and quality. The extracted studies showed substantial heterogeneity and therefore a meta-analysis was not performed.

CONCLUSION

The pharmacological management of pain secondary to non-reconstructable CLI is a challenging review topic. No recommendations of pharmacological agents can be made following this review but a number of novel approaches to manage pain in this cohort have shown positive results and require further investigation.

Digital gangrene induced by inadvertent intra-arterial cocktail injection of anesthetic agents such as pentazocine, promethazine, and atropine: A serious adverse drug experience

Gangrenous changes in skin due to accidental intra-arterial injection of promethazine and pentazocine have been reported. Accidental intra-arterial injection is most commonly encountered in the antecubital fossa. However, recent reports in the radial and ulnar arteries have also been encountered. We hereby report a serious, preventable adverse drug experience in the form of digital gangrene induced by inadvertent intra-arterial cocktail injection of anesthetic agents such as pentazocine, promethazine, and atropine, which seems to be in the radial artery as the lateral three digits and dorsum of the hand are affected.

Acquired Constricting Band Syndrome

The superstitious beliefs of gaining a good fortune led to wearing rubber bands around the hand leading to the development of the constricting band syndrome. Acute compartment syndrome is a limb-threatening condition characterized by elevated interstitial pressure in a confined fascial compartment and if left untreated, it results in tissue necrosis, irreversible nerve and muscle injury and permanent functional impairment. We report a 46 years old male with history of wearing rubber hand on all his fingers, who presented late with gangrene and autoamputation.

The Scleroderma Hand: Manifestations of Disease and Approach to Management

Scleroderma is a rare autoimmune connective tissue disorder that often affects the hands. Manifestations in the hands include calcium deposits within the soft tissues that cause pain and may ulcerate through the skin, digital ischemia resulting in chronic wounds and digital gangrene, and joint contracture. Because of the underlying disease, patients with scleroderma have poorly vascularized tissue and a deficient soft tissue envelope, which make surgery particularly challenging. However, when undertaken with care, surgical intervention is often the best option for addressing the disabling hand conditions that so often accompany this disease.

[Predictive factors of gangrenous post-appendectomy intra-abdominal abscess. A case-control study]

BACKGROUND

Acute appendicitis is the most frequent surgical urgency in children. Frequently, it can be complicated with an intraabdominal abscess that will require a longer and expensive treatment. Our aim is to know if it is possible to predict this complication before its beginning.

MATERIAL AND METHODS

Retrospective case-control study with patients treated between 2011 and 2016, paired according to their own characteristics (age, sex and weight), clinical aspects (symptoms, time of their onset, physical examination) and type of appendicitis (gangrenous). The main variable was the appearance of an intraabdominal abscess in the postoperative period (cases). Univariate and multivariate analysis were performed, with a statistical significance level of p < 0.05.

RESULTS

We included 54 cases and 108 controls. The occurrence of intraabdominal abscess was significantly associated with preoperative hyponatremia (p < 0.001), elevated CRP (p < 0.05), appendix perforation (p < 0.001) and wound infection (p < 0.001). The multivariate analysis dismissed the value of the CRP as an abscess predictor but showed association in the other three variables cited before. There was no association with the presence of generalized peritonitis at the intervention or the type of surgical approach.

CONCLUSIONS

Appendix perforation, infection of the surgical wound and hyponatremia at diagnosis are predictive factors for the appearance of a postoperative intraabdominal abscess after acute gangrene appendicitis. We believe that early identification would favor the secondary prevention of this complication and the decrease of its morbidity.

[Balloon angioplasty of the radial artery in critical hand ischaemia]

Presented herein are the results of treatment of five 63-to-72-year-old patients (four men and one woman) with critical upper limb ischaemia, which is one of rarely encountered pathologies. All patients suffered from type 2 diabetes mellitus. Two of them had end-stage renal disease (ESRD) and for 2 years were on haemodialysis. Four patients had gangrene of 1 finger and one patient had gangrene of 2 fingers. The main diagnostic methods included duplex scanning with measuring the gradient of pressure between the humeral and radial arteries, and MSCT angiography. The patients with ESRD received conservative therapy with the use of prostaglandin E1 and after limitation of necrosis sustained amputation of the fingers. Three patients were successfully managed by recanalization and balloon angioplasty of the radial artery's occluded segment. The patients underwent follow-up examinations at 1, 6, 12, 18 and 24 months. During this period two patients with ESRD died. They had no relapses of critical ischaemia of the hand but developed gangrene of toes and were both subjected to successful balloon angioplasty of the crural arteries. One patient at 18 postoperative months was found to have reocclusion of the radial artery with hand pain at rest. He was subjected to successful repeat balloon angioplasty of the radial artery. CONCLUSION: Timely restoration of blood flow in this situation reduces the frequency of amputation. Percutaneous balloon angioplasty may become a method of choice in treatment of patients with critical hand ischaemia caused by occlusive lesions of arteries of the forearm.

Rare complication of appendix: small bowel gangrene caused by the appendicular knot

Intestinal knot formation was first described by Riverius in 16th century and later by Rokitansky in 1836. We report a very rare cause of small bowel gangrene caused by appendiceal knotting on to the ileum in a previously healthy mid aged lady. Patient underwent laparatomy and right hemicolectomy and primary anastomosis. The intra operative findings were the appendix was twisting (knotting) the small bowel about 40cm from the terminal ileum and causing gangrene to the segment of small bowel. Appendicitis is a common condition and management is usually straightforward. However we must be aware of rare complications which may arise that require a change from the standard treatment of acute appendicitis.

[Extensive digital gangrene revealing late-onset systemic lupus erythematosus]

INTRODUCTION

Late-onset systemic lupus erythematosus represents a specific sub-group of the disorder, beginning after 50 years of age. The incidence is rarer and the course of the disease is considered to be more benign. Digital gangrene is an uncommon complication of systemic lupus erythematosus reported especially among middle-aged patients with long disease duration.

OBSERVATION

We report a 53-year-old man, who presented with systemic lupus erythematosus revealed by an extensive digital gangrene.

CONCLUSION

Digital gangrene is a rare complication of late onset systemic lupus erythematosus. Clinicians should be aware of this complication in order to initiate early and aggressive treatment.

Small Vessel Vasculitis, an Uncommon Presentation of Systemic Lupus Erythematosus

We report a nineteen year old female with gangrene of toes as the only clinical feature of systemic lupus erythematosus. She was treated successfully with pulse cyclophosphamide and steroid.

An unexpected gangrenous duplication of ileum

Alimentary tract duplication is a rare congenital anomaly which may involve any part of the alimentary tract extending from stomach to rectum. Clinical presentation may mimic an inflamed appendix as described in this case. A 9-year-old boy with a clinical diagnosis of perforated appendix was noted to have a normal appendix intra-operatively. On further search for an underlying pathology, a gangrenous ileal duplication was discovered. En-bloc resection with primary bowel anastomosis was done. Histopathology report revealed a gangrenous small bowel duplication. We discuss the preoperative diagnostic dilemma and management options in approaching this rare entity.

Carcinoma of Unknown Primary Presenting as Peripheral Symmetric Gangrene

Cancer of unknown primary accounts for almost 4-5% of all invasive cancers and consists of tumors from various primary sources with considerable heterogeneity in biology and behaviour. Most of these tumors present with symptoms due to distant metastasis. Histology, immunohistochemistry and molecular profiling is the mainstay for diagnosis. In most cases of adenocarinoma associated with paraneoplastic acral vascular syndrome (PAVS), a site in the lung, ovary or uterus is discernible. Here we report a case of metastatic adenoarcinoma of unknown primary presenting as PAVS, a case which to the best of our knowledge has not been reported in published literature.

Gallstone ileus presenting as obstructive gangrenous appendicitis

We present the very unusual case of a 38-year-old woman with acute appendicitis and intestinal obstruction. During surgery, a 2.5 cm gallstone impacted at the base of the cecal appendix was found as the cause of a gangrenous appendicitis and obstruction; a choledochal-duodenal fistula was found during the same surgery with no gallstones remaining in the gallbladder or elsewhere. The case was managed by appendectomy with retrieval of the gallstones and no other procedure was performed for the gallbladder or the fistula, since no other gallstone was found on examination. Previously, she was found to have a round, radio-opaque image on the right iliac fossa on imaging, initially identified as an appendicolith, but after pathological examination it turned out to contain cholesterol and calcium bilirubinate. Gallstone ileus as the cause of an obstructive gangrenous appendicitis is a very unusual disease presentation that should be kept in mind when finding an unusual appendicolith presentation in or out the appendix.

Hemodialysis patient with finger ulcerations

The patient reported pain and paresthesias of his left ring finger, and his left hand was cooler than his right. An angiogram helped us recognize the cause of his symptoms.